Polymyalgia Rheumatica Activity Score Research Articles

Concordance and agreement between different activity scores in polymyalgia rheumatica

ObjectiveThe C reactive protein polymyalgia rheumatica activity score (CRP-PMR-AS) is a composite index that includes CRP levels and was developed specifically for PMR. As treatments such as interleukin-6 antagonists can...

Methods for assessment of disease activity of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is the second most frequent inflammatory rheumatic disease in old age. Remission and recurrence are frequently used as endpoints in clinical trials; however, there is as yet no international consensus on the definition of these states, which limits the comparability of published studies. The PMR activity score (PMR-AS) is the only composite score specifically developed for PMR, which together with remission is used to define low, middle and high disease activity. In recent studies the PMR-AS was often used and low disease activity was established as endpoint. The most important limitation of the PMR-AS is the potential influence of the individual variables by comorbidities. The value of C‑reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) are of restricted value in studies using drugs that influence the interleukin 6 (IL-6) axis. In these cases, calprotectin and osteopontin are promising alternative biomarkers, as they have already been shown to reflect disease activity independently of CRP in rheumatoid arthritis. Furthermore, imaging modalities including sonography, magnetic resonance imaging and fluorodeoxyglucose (FDG) positron emission tomography could also be helpful in monitoring disease activity; however, these techniques must first be validated in further studies. The PMR impact scale (PMR-IS) is acomposite score to assess the impact of PMR on the patients; however, it has not yet been used in clinical studies. The development of additional patient reported outcomes (PRO) for PMR and the definition of standardized criteria for documentation of remission and recurrence are important questions in the future research agenda for PMR.

Measurement Properties of the Polymyalgia Rheumatica Activity Score: A Systematic Literature Review.

To perform a COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)-based systematic literature review of measurement properties of the Polymyalgia Rheumatica Activity Score (PMR-AS). PubMed, EMBASE, and CINAHL were broadly searched. English full-text articles, with (quantitative) data on ≥ 5 patients with PMR using the PMR-AS were selected. Seven hypotheses for construct validity and 3 for responsiveness, concerning associations with erythrocyte sedimentation rate, physical function, quality of life, clinical disease states, ultrasound, and treatment response, were formulated. We assessed the structural validity, internal consistency, reliability, and measurement error, or the hypotheses on construct validity or responsiveness of the PMR-AS based on COSMIN criteria. Out of the identified 26 articles that used the PMR-AS, we were able to use 12 articles. Structural validity, internal consistency, construct validity, and responsiveness were assessed in 1, 2, 8, and 3 articles, respectively. Insufficient evidence was found to confirm structural validity and internal consistency. No data were found on reliability or measurement error. Although 60% and 67% of hypotheses tested for construct validity and responsiveness, respectively, were confirmed, there was insufficient evidence to meet criteria for good measurement properties. While there is some promising evidence for construct validity and responsiveness of the PMR-AS, it is lacking for other properties and, overall, falls short of criteria for good measurement properties. Therefore, further research is needed to assess its role in clinical research and care.

Not just pain and morning stiffness duration in the daily experience of patients with polymyalgia rheumatica. Does the rheumatologist listen to all patient-reported outcomes?

Patient-reported outcomes (PROs) provide a means for patients to communicate with their care teams about their disease. Polymyalgia rheumatica (PMR) is considered to be one of the most common inflammatory rheumatic diseases in older adults. The Visual Analogue Scale (VAS) of pain is the only PRO assessed by the PMR activity score (PMR-AS), which is still the only validated score for monitoring disease activity in patients affected with PMR. Other PROs such as fatigue, sleep disturbances, depressive symptoms, and patient’s perspective related to adverse effects of prednisolone are still unmet needs. This short communication suggests the gerontorheumatological outpatient clinic as an answer.

Efficacy of first-line tocilizumab therapy in early polymyalgia rheumatica: a prospective longitudinal study

BackgroundGlucocorticoids are the cornerstone treatment of polymyalgia rheumatica (PMR) but induce adverse events.ObjectivesTo evaluate the efficacy and safety of first-line tocilizumab in PMR.MethodsIn a prospective open-label study (ClinicalTrials.gov: NCT01713842), 20...

AB0596 Glucocorticoid-Resistant Polymyalgia Rheumatica: Clinical Characterization and TOCILIZUMAB Therapy

BackgroundTreatment with glucocorticoid (GC) is the preferred therapy for polymyalgia rheumatica (PMR), but half of the PMR patients experience a flare-up(s) of disease activity upon GC tapering or discontinuation. In...

FRI0224 Plasma fibrinogen is an accurate marker of disease activity in patients with polymyalgia rheumatica

BackgroundDetermination of disease activity in polymyalgia rheumatica (PMR) is challenging due to the subjective nature of symptoms and prevalence of concurrent musculoskeletal complaints in an elderly population. Traditionally the non...

Contribution of the Polymyalgia Rheumatica Activity Score to Glucocorticoid Dosage Adjustment in Everyday Practice

To evaluate the usefulness of the polymyalgia rheumatica (PMR) activity score (PMR-AS) in guiding adjustment of glucocorticoid (GC) dosage. Rheumatologists prospectively included patients receiving GC therapy for PMR. At each visit, they assessed disease activity using a visual analog scale for physician's global assessment (VASph) and recorded whether a flare was diagnosed and/or the GC dosage was changed. In each patient, the PMR-AS was calculated using the formula of Leeb and Bird: C-reactive protein (mg/dl) + VAS pain score (0 to 10) + VASph (0 to 10) + (morning stiffness in min × 0.1) + elevation of upper limbs (0-3). We evaluated the correlation between PMR-AS and GC dosage changes in the group already treated with GC. We included 89 patients (mean age 74.6 ± 6.2 yrs; disease duration 1.6 ± 2.2 yrs), who had a total of 149 visits. PMR-AS was available for 137 visits. Of those, 124 involved patients already treated with GC, and 13 patients who started GC treatment. The Spearman correlation coefficient between PMR-AS values and GC dosage change was 0.58 (p < 0.001). In the group already treated with GC, when the PMR-AS was higher than 20, GC dosages were never decreased. When the PMR-AS was between 10 and 20, GC dosages were decreased in 4 patients, unchanged in 4, and increased by < 5 mg in 4 patients. When PMR-AS was < 10, GC dosages were generally decreased. The PMR-AS is helpful for diagnosing flares of PMR and may also assist in everyday practice to decide how to change the GC dosage.

Effect of etanercept in polymyalgia rheumatica: a randomized controlled trial

IntroductionTo elucidate in polymyalgia rheumatica (PMR) the role of tumor necrosis factor (TNF) α and the therapeutic potential of blockade with soluble TNF-α receptor, we carried out the first randomized controlled trial with etanercept in PMR.MethodsTwenty newly diagnosed, glucocorticoid (GC) naïve patients with PMR and 20 matched non-PMR control subjects completed the trial. Subjects were randomized in a 1:1 ratio to monotherapy with etanercept (25 mg s.c. biweekly) or placebo (saline) for 14 days. Study outcomes were assessed at baseline and after 14 days. The primary outcome was the change in PMR activity score (PMR-AS). Secondary outcomes were: changes in erythrocyte sedimentation rate (ESR) and plasma levels of TNF-α and interleukin (IL) 6; patients' functional status (health assessment questionnaire) and cumulative tramadol intake during the trial.ResultsAt baseline, plasma TNF-α was higher in patients than in controls (P < 0.05). The concentration always increased with etanercept treatment (P < 0.05). In patients, etanercept decreased PMR-AS by 24% (P = 0.011), reflecting significant improvements in shoulder mobility, physician's global assessment and C-reactive protein, and insignificant (P > 0.05) improvements in duration of morning stiffness and patient's assessment of pain. In parallel, ESR and IL-6 were reduced (P < 0.05). Placebo treatment did not change PMR-AS, ESR and IL-6 (P > 0.05). Functional status did not change and tramadol intake did not differ between patient groups. In controls, no changes occurred in both groups.ConclusionsEtanercept monotherapy ameliorates disease activity in GC naïve patients with PMR. However, the effect is modest, indicating a minor role of TNF-α in PMR.Trial registrationClinicalTrials.gov (NCT00524381).

Diagnose und Monitoring bei Polymyalgia Rheumatica

Die Polymyalgia rheumatica (PMR) stellt eine häufige Erkrankung der älteren Bevölkerungsgruppe dar. Die Diagnose wird üblicherweise anhand des klinischen Erscheinungsbildes mit Schmerzen und Steifigkeit im Schultergürtel und Beckengürtel, Druckschmerz der Muskulatur der Oberarme und Oberschenkel und weiterer unspezifischer Symptome gestellt. In den meisten Fällen findet sich auch eine deutliche Erhöhung von Blutsenkung (BSG) und C reaktivem Protein (CRP). In Ermangelung eines definitiven diagnostischen Tests werden Kriteriensets zur Diagnosestellung angewandt. Von diesen erwiesen sich die Bird/Wood Kriterien als diejenigen mit der höchsten Sensitivität (99,5%). Generell kann die Prognose der PMR als ausgezeichnet angesehen werden. Es ist allgemein bekannt, dass Corticosteroide normalerweise zu einer raschen und nachhaltigen Besserung des Beschwerdebildes führen. Die EULAR Response Kriterien für PMR umfassen ein Parameterset, nämlich die Schmerzangabe des Patienten anhand einer Visuellen Analogskala (VAS), die Arzteinschätzung des Schweregrades der Erkrankung mittels VAS, den Wert des CRP oder der BSG, die Beweglichkeit der oberen Extremitäten und die Dauer der Morgensteifigkeit. Um die Krankheitsaktivität auch in Form einer absoluten Zahl ausdrücken zu können, wurde aus den EULAR Response Kriterien der PMR-activity score (PMR-AS) entwickelt. Werte zwischen 0 und 1,5 zeigen dabei eine Remission, Werte <7 niedrige, Werte >7<17 mittlere und Werte >17 hohe Krankheitsaktivität an. Der PMR-AS erwies als hoch signifikant mit der globalen Patienteneinschätzung, der Patientenzufriedenheit und der BSG korreliert. Damit wurde bestätigt, dass dieser Score ein valides und leicht anzuwendendes Instrument zum Monitoring des Verlaufes und der Therapieantwort bei PMR-Patienten darstellt. Es kann vorhergesehen werden, dass eine mehr systematische Diagnosestellung, exakteres Monitoring des Krankheitsverlaufes, wie auch eine verbesserte Nutzen-Risiko-Evaluierung der Therapie zu einer Verbesserung der Situation von PMR-Patienten beitragen kann.

Validity of the polymyalgia rheumatica activity score in primary care practice

Objective:To evaluate the validity and reliability of the polymyalgia rheumatica (PMR) activity score (PMR-AS) for relapse diagnosis by general practitioners (GPs) who manage a large proportion of patients with PMR.Methods:Seven...

Performance of the polymyalgia rheumatica activity score for diagnosing disease flares

To evaluate the effectiveness of the polymyalgia rheumatica activity score (PMR-AS) in diagnosing disease flares. Rheumatologists prospectively included 89 patients with PMR (mean +/- SD age 74.6 +/- 6.2 years, mean +/- SD disease duration 1.6 +/- 2.2 years). At each visit, the rheumatologist assessed disease activity using a visual analog scale (VAS) and recorded whether a disease flare was diagnosed and/or the glucocorticoid dose changed. Overall, 137 visits including 49 pairs (allowing intraindividual comparisons) were available; a disease flare was diagnosed at 32 visits. We evaluated statistical associations linking flare diagnosis to the PMR-AS, each of its components (VAS, VAS for pain, C-reactive protein, morning stiffness, and elevation of upper limbs), and changes in these parameters between 2 visits. Associations with disease flare diagnosis were strongest for PMR-AS scores > or =9.35 (agreement 92%, 95% confidence interval [95% CI] 85.8-95.7%, kappa = 0.78; sensitivity 96.6%, 95% CI 80.4-99.8; specificity 90.7%, 95% CI 83.2-95.2) and for DeltaPMR-AS scores > or =6.6 (agreement 98%, 95% CI 88.0-99.9%, kappa = 0.95; sensitivity 100%, 95% CI 74.7-100; specificity 97.1%, 95% CI 82.9-99.8). Other parameters showed weaker diagnostic performance. This study supplies new evidence that the PMR-AS is useful for monitoring PMR activity in everyday practice and for managing glucocorticoid tapering. PMR activity changes seem even more relevant than absolute values.

The polymyalgia rheumatica activity score in daily use: Proposal for a definition of remission

To confirm the reliability and applicability of the Polymyalgia Rheumatica Disease Activity Score (PMR-AS), and to establish a threshold for remission. First, 78 patients with PMR (50 women/28 men, mean age 65.97 years) were enrolled in a cross-sectional evaluation. The PMR-AS, patient's satisfaction with disease status (PATSAT; range 1-5), erythrocyte sedimentation rate (ESR; first hour), and a visual analog scale of patients' general health assessment (VAS patient global; range 0-100) were recorded. Subsequently, another 39 PMR patients (24 women/15 men, mean age 68.12 years) were followed longitudinally. Relationships between the PMR-AS, PATSAT, ESR, and VAS patient global were analyzed by the Kruskal-Wallis test, Spearman's rank correlation, and kappa statistics. PMR-AS values in patients with a PATSAT score of 1 and a VAS patient global <10 formed the basis to establish a remission threshold. PMR-AS values were significantly related to PATSAT (P < 0.001), VAS patient global (P < 0.001), and ESR (P < 0.01). PATSAT and VAS patient global were reasonably different (kappa = 0.226). The median PMR-AS score in patients with PATSAT score 1 and VAS patient global <10 was 0.7 (range 0-3.3), and the respective 75th percentile was 1.3. To enhance applicability, a range from 0 to 1.5 was proposed to define remission in PMR. The median ESR in these patients was 10 mm/hour (range 3-28), indicating external validity. We demonstrated the reliability, validity, and applicability of the PMR-AS in daily routine. Moreover, we proposed a remission threshold (0-1.5) founded on patient-dependent parameters.

Usefulness of the disease activity scores for polymyalgia rheumatica for predicting glucocorticoid dose changes: A study of 243 scenarios

To evaluate associations linking glucocorticoid dose changes in patients with polymyalgia rheumatica (PMR) to the PMR activity score (PMR-AS) and its components. Nine clinical vignettes of PMR were written by a panel of experts and submitted to 35 rheumatologists, who were asked to assess disease activity using a visual analog scale (VASph) and to determine whether there was a relapse of PMR requiring an increase in the glucocorticoid dose. In 7 vignettes, >80% of the rheumatologists agreed on the diagnosis of relapse justifying the glucocorticoid dose decision. A total of 243 vignette-physician combinations were obtained. Using these vignettes, we evaluated statistical associations linking a decision to increase the glucocorticoid dose to the value of PMR-AS, of its components (VASph, visual analog scale for pain [VASp], C-reactive protein level [CRP], morning stiffness [MST], and elevation of upper limbs [EUL]), or to the difference in these variables between the last 2 visits (dPMR-AS, dVASph, dVASp, dCRP, dMST, and dEUL). The strongest associations with a decision to increase the glucocorticoid dose occurred with dPMR-AS >4.2, dMST >10 minutes, dVASph >1.55, and dCRP >4 mg/dl (99.3% sensitivity, 100% specificity for all 4 variables); MST >or=10 minutes (100% sensitivity, 99.3% specificity); PMR-AS >or=7 (98.1% sensitivity, 94.3% specificity); VASph >or=2.25 (94.2% sensitivity, 83.6% specificity); and CRP level >or=14.5 mg/liter (66.3% sensitivity, 99.3% specificity). Despite inter-individual variations in VASph, PMR-AS was a good indicator of disease activity. However, MST, dMST, dVASph, dPMR-AS, and dCRP performed better than PMR-AS. These variables may be useful in tailoring the glucocorticoid dose to the individual needs of each patient.